Training in palliative and end-of-life care: Guidance for trainees (and their trainers) in non-palliative medicine training posts August 204 Produced by Dr Fiona Hicks onsultant in Palliative Medicine
ackground Physicians practising in general internal medicine (GIM), acute internal medicine (AIM) and most medical specialties commonly manage illness in patients who may be in the last phase of their lives, both as inpatients and outpatients, and decision making about their preferences for treatment and care should routinely be a joint process with patients and their families. Ensuring that this is the normal or default approach, coupled with specific attitudes and skills to manage end-of-life care (EoL) discussions sensitively and manage symptoms optimally are core attributes of good doctors. The key competences expected are shown in the curriculum extracts in section four. There are approximately 6500 trainees in higher training (ST3 and above), up to 50% of whom undertake dual training with GIM. Most of these will require some palliative care (P) skills for patients in the last phase of life (LPoL) which may range from hours/days to many months. The UK annual intake of trainees requiring these skills amounts to about 000 pa. At deanery level, this means that on average there will be 80 trainees eligible for enhanced training per year, but the numbers will vary from 20-50 pa depending on the size of the deanery / LET. Specialties requested guidance for how the required competences can be gained for use at training programme level. This document focusses on the training methods rather than the competencies required. Guidance for trainees, trainers and programme directors Although the curricula are competency-based, there is also a minimum indicative time required, recognising that experience is very important in gaining competency. The following excerpt from the geriatric medicine curriculum suggests how competency can be gained: Work directly with a consultant-led palliative care team on a full-time or part-time basis (eg one day per week over four-five months) Assess new and follow-up patients and discuss with educational supervisor Work within a variety of settings eg hospice, specialist palliative care unit, day hospice, general hospital outpatients Attendance at specialist palliative care MDT meetings Small group sessions with other trainees (Geriatrics and/or Palliative are) Education ourses - Palliative are, ommunication Reflection in log-book/e-portfolio Participation in audit and research Although elements of the competencies required will be gained at various times, it is useful to specify a minimum requirement so that trainees and trainers can identify needs and demonstrate competencies gained. http://www.rcplondon.ac.uk/projects/future-hospital-commission
It is anticipated that the minimum indicative time requirement to gain the curriculum competencies will be 40 hours (equivalent to five working days). Time spent on the WPA (and associated feedback) can be included. It is recommended that a minimum of one supervised learning events (SLEs) are carried out (at least one bd, and one ) which predominantly relate to palliative care and EoL issues, are undertaken. Examples of topics to be covered are listed below. Once the trainee believes that they have adequately explored the competencies they should complete the trainee rating section of the curriculum grid in the e- Portfolio. This should be reviewed by the supervisor (clinical or educational) and the competency status confirmed. Guidance for how to achieve (and document) a minimum competency level, and some examples of excellence is outlined in the table below. Domain and indicative time Knowledge 8 hours Skills and behaviours 6 hours Experience 6 hours Examples of how knowledge, skills & behaviours can be achieved Personal reading, elearning (see below), attendance at formal lectures / grand rounds / seminars / tutorial, any relevant PD Reflection on personal involvement with patients / P / EoL events ommunication skills course Use of simulation Use of patient /family feedback about the extent to which they feel involved as a part of reflective learning Period of time / sessions with a P team (hospice / hospital / community) where assessment of patients with P needs is undertaken Attend M&M meetings Opportunistic joint visits with palliative medicine colleagues/patient assessments and reviews on wards or in outpatients Minimum requirement to demonstrate exploration of curriculum At least 3 hours of specific, formal palliative care teaching / lectures Initiate a discussion about EoL (more than N) Manage a patient s care through their last days of life according to the principles of an agreed EoL care plan Generic communication skills course Demonstrate patient led decision making and attaching value to patient preferences 2 sessions (of at least 3 hours each) or equivalent, with a palliative medicine team (community / hospice or hospital) with documentation of, and reflection on, experience and feedback Examples of excellence MSc / Diploma / certificate / approved course Advanced communication skills course Review of hospital complaints re events surrounding deaths Write a discussion / reflection document (case, ethical / comm dilemma/ reflection on patient feedback) Participate in audit / QI project 2 weeks Experience with specific MDTs (eg GP GSF meetings) Visits with District Nurses and day centres ereavement teams Detailed documentation of skills gained and development needs Assessment methods bd Mini-EX SE MSF Mini-EX AAT (eg care of patients seen during attachment) DOPS (eg syringe driver prescription / set up) AA/QIPAT AAT bd Mini-EX
Suggested topics for (adapted from the palliative medicine curriculum). ommunication with patients and families (eg N, developing a joint care plan with a patient covering the last months of life, advance care planning, DNA-PR) 2. linical evaluation / examination for symptom management, including emergencies 3. Supporting a family in conflict in relation to unrealistic goals 4. Assessing the dying patient 5. linical evaluation and on-going care of the dying patient 6. Prescribing in organ failure 7. Evaluation of psychological response of patient & relatives to illness and supporting patients needs 8. Evaluating and supporting spiritual and religious needs 9. Supporting patients to make their preferred choices and manage own their health needs Suggested topics for bd (adapted from the palliative medicine curriculum). Shared decision making in the management of symptoms / clinical problems (including intractable symptoms and emergencies) 2. Pharmacology / therapeutics, including opioid use and opioid switching 3. Other interventions in pain management 4. Recognition, assessment and management of critical change in patient pathway 5. Management of concurrent clinical problems 6. Psychosocial care and support in relation to distress, grief and bereavement 7. ommunication with colleagues and between services, shared care 8. Ethics 9. Team-working E-Learning sessions recommended to support curriculum delivery www.e-lfh.org.uk/projects/end-of-life-care/ ourse Section Advance are Planning Integrating Learning Spirituality Session ode and Title 0_0 Introduction to principles of AP 0_05 Advance Decision to Refuse Treatment: principles 0_2 How to get started and get the timing right 03_5 reaking bad news 04_23 Recognising the dying phase, last days of life and verifying death 05_0 Initiating conversations about EoL: OPD 05_03 Initiating conversations about EoL: dementia 08_02 Understanding and Assessing Spiritual Need and Spiritual Distress Future possibilities onsider incorporating questions into knowledge-based assessment (KA).
urriculum extracts The following extracts from the MT, AIM and GIM curricula represent the minimum knowledge, skills and behaviours required for the level of training. The third table provides an overview of the palliative medicine specialty syllabus and specifies the level of knowledge / skills / behaviour required for non-palliative medicine trainees. The following curricula also contain syllabus sections on palliative medicine: ardiology End of Life are in ardiology, page 63 Geriatric medicine Palliative are, page 70 Gastroenterology Management of patients requiring palliative and end of life care, page 56 Infectious diseases Management of Patients Requiring Palliative and End of Life are, page 8 Immunology curriculum Palliative are, page 9 Respiratory medicine Palliative are, page 3 Stroke medicine To provide appropriate end-of-life care for stroke patients, page 5 Table : Management of Patients Requiring Palliative and End of Life are MT To be able to work and liaise with a multi-disciplinary team in the management of patients requiring palliative and end of life care. To be able to recognise the dying phase of a terminal illness, assess and care for a patient who is dying and be able to prepare the patient and family. To be able to support patients to develop an appropriate management plan and facilitate planning of EoL choices including advance care planning Knowledge Assessment Methods GMP Describe different disease trajectories and prognostic indicators and the signs that a patient is dying Know that specialist palliative care is appropriate for patients with other life threatening illnesses as well as those with cancer Describe the pharmacology of major drug classes used in palliative care, including opioids, NSAIDS, agents for neuropathic pain, bisphosphonates, laxatives, anxiolytics, and antiemetics. Describe common side effects of drugs commonly used MRP(UK) Part, Part 2, AAT, bd, AAT, bd,,3 MRP(UK) Part, MRP(UK) Part 2, AAT, bd, Describe the analgesic ladder, role of radiotherapy, surgery and other nonpharmacological treatments MRP(UK) Part, Part 2, AAT, bd, mini- EX Describe advance care planning bd, Knowledge of a spectrum of professional and complementary therapies available, e.g. palliative medicine, hospice and other community services, nutritional support, pain relief, psychology of dying. bd,, PAES,2 Know about End of Life Integrated are Pathway documentation e.g. Liverpool IP for the last days of life AAT, bd, Know about the use of syringe drivers AAT, bd, Outline spiritual care services & when to refer bd,
Describe the role of the coroner and when to refer to them AAT, bd, Skills Recognising when a patient may be in the last days / weeks of life MRP(UK) Part, Part 2, AAT, bd, e able to assess the patient s physical, psychological and social needs AAT, bd, Is able to take an accurate pain history, recognising that patients may have multiple pains and causes of pain Is able to prescribe opioids correctly and safely using appropriate routes of administration Able to assess response to analgesia and recognise medication side effects or toxicity AAT, bd, AAT, bd,, 2 AAT, bd,, 2 Is able to assess and manage other symptom control problems including nausea and vomiting, constipation, breathlessness, excess respiratory tract secretions, agitation, anxiety and depression Recognise that the terminally ill often present with problems with multi-factorial causes some of which may be reversible MRP(UK) Part, Part 2, AAT, bd, MRP(UK) Part, Part 2, AAT, bd, ommunicate honestly and sensitively with the patient (and family), about the benefits and disadvantages of treatment and appropriate management plan, allowing the patient to guide the conversation. Able to elicit understanding and concerns. AAT, bd,,3,4 Is able to document discussion clearly, and communicates relevant parts to other involved carers appropriately. bd,,3 Practice safe use of syringe drivers MRP(UK) Part, Part 2, AAT, bd, omplete death certificates and cremation forms AAT, bd, ehaviours o-ordinates care within teams, between teams and between care settings AAT, bd,,3,2 Active management, regular review of patient priorities and preferences, and ongoing assessment of symptoms Refers to and liaises with specialist palliative care services when recognises that care is complex AAT, bd, AAT, bd,,2,3
Table 2: Management of Patients Requiring Palliative and End of Life are AIM & GIM To be able to work and liaise with a multi-disciplinary team in the management of patients requiring palliative and terminal care. To be able to recognise the dying phase of a terminal illness, assess and care for a patient who is dying and be able to prepare the patient and family. To facilitate advance care planning, the establishment of aims of care Knowledge Assessment GMP Knowledge of spectrum of professional and complementary therapies available, e.g. palliative medicine, community services, nutritional support, pain relief, psychology of dying. Methods bd,2 Describe different disease trajectories and prognostic indicators and the signs that a patient is dying Know about Advance are Planning documentation and End of Life Integrated are Pathway documentation e.g. Liverpool IP for the Last Days of Life Knowledge of major cultural & religious practices relevant to the care of dying people and demonstrating ability to support patients in choices relating to these AAT, bd, AAT, bd, bd, Describe the role of the coroner and when to refer to them bd, Skills Delivery of effective pain relief, symptom control (including for agitation, excessive respiratory secretions, nausea & vomiting, breathlessness), spiritual, social and psychological management. MSF, bd, ehaviours Refers to specialist palliative care services when recognises that care is complex AAT, bd,,2,3 Recognises the needs of the carers and is able to support them AAT, bd,,2,3
Table 3: System competency Palliative are and End of Life are Key A Establishing a diagnosis Establishing a diagnosis Knowledge of relevant investigations Establishing a diagnosis Knowledge of relevant investigations and management Knowledge of prognosis and likely response to therapy The trainee will acquire the defined knowledge base of clinical science and common problems with applied competences in Palliative are ompetences Take an accurate pain history Recognise that the terminally ill often present with problems with multi-factorial causes Recognise associated psychological and social impact e able to elicit patients priorities and perspectives and jointly agree a management plan with patients and their carers / family that supports these Recognise when a palliative care specialist opinion is needed ontribute to discussions on decisions not to resuscitate with patient, carers, family and colleagues appropriately and sensitively ensuring patients interests are paramount Degree of Knowledge Assessment Methods PAES, AAT, bd MRP(UK) Part 2, PAES AAT, bd, MRP(UK) Part 2, PAES AAT, bd, PAES. AAT, bd, PAES, AAT, bd, GMP PAES, AAT, bd,,3,4 Recognise the dying phase of terminal illness PAES, AAT, bd, Manage symptoms in dying patients appropriately MRP(UK) Part 2, PAES AAT, bd, Practice safe use of syringe drivers AAT, bd,,2 Recognise importance of hospital and community Palliative are teams Recognise that referral to specialist palliative care is appropriate for patients with other life threatening illnesses as well as those with cancer ommon Problems Palliative are Pain: PAES, AAT, bd PAES, AAT, bd appropriate use MRP(UK) Part and Part 2
analgesic ladder MRP(UK) Part and Part 2 side effects MRP(UK) Part and Part 2 role of Radiotherapy A MRP(UK) Part 2 onstipation reathlessness Nausea and vomiting Anxiety and depressed mood linical Science MRP(UK) Part and Part 2 MRP(UK) Part and Part 2 MRP(UK) Part and Part 2 MRP(UK) Part and Part 2 Pharmacology of major drug classes in palliative care: anti-emetics, opioids, NSAIDS, agents for neuropathic pain, bisphosphonates, laxatives, anxiolytics MRP(UK) Part and Part 2 PAES